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TARGET THERAPY<br />
Staying on Target TM<br />
S T AY I N G O N T A R G E T <br />
Your <strong>Insulin</strong> <strong>Adjust</strong>ment <strong>Workbook</strong><br />
Yes, You Can Do It!
YES, YOU CAN DO IT!<br />
Your ‘How-To’ Guide for<br />
<strong>Adjust</strong>ing Basal and Bolus <strong>Insulin</strong><br />
This workbook will help you learn new skills so that you can you live a<br />
healthier life with your diabetes. “What is Basal-Bolus?” introduces<br />
flexible insulin therapy, (also called intensive therapy) as a way to correct<br />
your blood glucose levels. “Terms to Learn First” gives you the definitions<br />
that you will need. “Making Bolus <strong>Insulin</strong> Changes,” outlines how to<br />
make changes to rapid and short acting insulin doses. “Putting it All<br />
Together” gives you a plan to get started. “<strong>Adjust</strong>ing for Basal <strong>Insulin</strong>,”<br />
explains changing long acting insulin doses. “Trouble-Shooting,” tells<br />
what to do when you are having a hard time. “Problem-Solving and<br />
Exercises” gives you a chance to practice what you learned. Use this guide<br />
as you work with your diabetes health care team to help you avoid the<br />
complications of diabetes.<br />
<strong>BD</strong> provides this workbook for informational purposes only. It is not intended to be a substitute for professional<br />
medical advice, diagnosis or treatment. Always seek the advice of your physician or other qualified healthcare<br />
provider with any questions you may have regarding a medical condition. Never disregard professional medical advice<br />
or delay in seeking it because of something you have read in this workbook
INTERACTIVE TABLE OF CONTENTS<br />
To go directly to the topic of interest, click on the link below.<br />
WHAT IS BASAL-BOLUS? ........................1<br />
Managing Your Blood Glucose....................2<br />
Practicing Flexible / Intensive Therapy..........2<br />
Responsibilities / Rewards of Basal-Bolus ....2<br />
‘Normal’ <strong>Insulin</strong> Delivery ............................3<br />
TERMS TO LEARN FIRST ..........................4<br />
Blood Glucose Goals ..................................5<br />
Target Glucose............................................5<br />
Algorithm ..................................................5<br />
Basal <strong>Insulin</strong>................................................6<br />
Bolus <strong>Insulin</strong> ..............................................6<br />
<strong>Insulin</strong> <strong>Adjust</strong>ment and<br />
Pattern Management..................................7<br />
<strong>Insulin</strong> Sensitivity Factor (ISF)<br />
and Correction ..........................................7<br />
Peak Action ................................................8<br />
MAKING BOLUS INSULIN CHANGES ......9<br />
Understanding How <strong>Insulin</strong> Works............10<br />
Blood Glucose Monitoring:<br />
When to Test ............................................12<br />
Making Changes Using<br />
Pattern Management................................13<br />
Correcting for Blood Glucose<br />
That is Out of Range ................................17<br />
Correction Method I............................18<br />
Correction Method II ..........................18<br />
Correction Method III ..........................19<br />
Calculating Your <strong>Insulin</strong><br />
Sensitivity Factor (ISF)................................19<br />
<strong>Insulin</strong>/Blood Glucose Formula ............19<br />
Rule of 1500 ......................................21<br />
Rule of 1700 ......................................23<br />
Correcting for Known Changes<br />
in Meals or Exercise ..................................25<br />
Correcting for a Change in Meals ......25<br />
Calculating Your Carb:<strong>Insulin</strong> Ratio ....25<br />
Method I ............................................26<br />
Method II ............................................26<br />
Correcting for a Known<br />
Change in Exercise ..............................29<br />
PUTTING IT ALL TOGETHER ..................30<br />
Getting Started: A Five-Step Plan..............31<br />
Practice Problems......................................31<br />
ADJUSTING THE BASAL DOSE ..............34<br />
Testing the Nighttime Basal ......................35<br />
Testing the Daytime Basal ........................37<br />
Option I ..............................................37<br />
Option II..............................................38<br />
Option III ............................................38<br />
TROUBLESHOOTING ..............................39<br />
PROBLEM SOLVING AND EXERCISES ....44<br />
SEE – YOU REALLY CAN DO IT! ............49
WHAT IS BASAL-BOLUS?<br />
1
WHAT IS BASAL-BOLUS?<br />
When you have diabetes, it is important<br />
to avoid high and low blood glucose<br />
(sugar). This section reviews how outof-control<br />
blood glucose can lead to<br />
diabetes complications. It also introduces<br />
flexible/intensive therapy with basal-bolus<br />
insulin adjustment1 as a way to help<br />
keep you healthy.<br />
Managing Your Blood<br />
Glucose – Keeping in control means<br />
that your blood glucose is always in a<br />
range that is not too high or too low.<br />
Controlling blood glucose helps you stop<br />
or delay the risk of developing eye, kidney,<br />
nerve, foot and heart disease caused by<br />
blood glucose that is too high for a long<br />
period of time. It can be hard to stay<br />
in control with one, two, or even three<br />
injections of insulin a day. You can still<br />
have many times when the insulin does<br />
not match your food or exercise, so your<br />
blood glucose gets too high or too low.<br />
Practicing Flexible / Intensive<br />
Therapy – Research shows that flexible<br />
(also called intensive) insulin therapy can<br />
work to control blood glucose levels in<br />
most people. With this therapy you:<br />
1. Take four or more insulin injections a<br />
day, adjusting your insulin doses as<br />
needed to keep your blood glucose<br />
within your goal range OR<br />
2. Use an insulin pump.<br />
The goal is to keep your blood glucose close<br />
to normal by taking insulin to match the<br />
quantity of food you eat and also meet your<br />
body’s needs at other times. The insulin<br />
that works between meals and through the<br />
night is called “basal.” The insulin that<br />
works to match food or lower high blood<br />
glucose is called “bolus.” “Basal-bolus” is<br />
a term used by health care professionals<br />
to describe flexible therapy.<br />
Responsibilities / Rewards<br />
of Basal-Bolus – Before starting<br />
flexible (basal-bolus) therapy, you<br />
should think about its pros and cons.<br />
“Pros” – You will have more freedom<br />
and other benefits, such as:<br />
• Ability to eat when and how<br />
much you want<br />
• Freedom to skip a meal<br />
• Better diabetes control<br />
• Feeling of greater well-being<br />
• Reduced risk of complications<br />
“Cons” – You will have more work,<br />
including:<br />
• Checking blood glucose four or more<br />
times a day, and sometimes during<br />
the night<br />
• Learning and practicing carbohydrate<br />
(carb) counting<br />
1 All glucose values used in this workbook are plasma values. If you use a blood glucose meter that reads whole<br />
blood values, you should decrease them by about 10%.<br />
2
• Deciding on your insulin dose<br />
according to the amount of carb<br />
you expect to eat and the exercise<br />
or activity you plan<br />
Although some people can have frequent<br />
or severe hypoglycemia (low blood<br />
glucose) with this therapy, most people<br />
have less because there is a better match<br />
between their insulin and food. You can<br />
adjust flexible therapy for your lifestyle,<br />
eating and sleeping schedules and<br />
physical activity. You will learn to match<br />
your insulin to your food, exercise, and<br />
adjust for high or low blood glucose<br />
when it happens.<br />
‘Normal’ <strong>Insulin</strong> Delivery –<br />
A diabetes-free pancreas releases a small<br />
amount of insulin throughout the day<br />
and night. This insulin is described as<br />
basal and is steadily discharged from the<br />
pancreas so that there is always some<br />
available. At night and between meals,<br />
basal insulin works with a small amount<br />
of glucose made by the liver that is also<br />
being constantly released. After eating a<br />
meal or snack with carb in it, two things<br />
happen:<br />
1. Blood glucose rises.<br />
2. The pancreas releases an extra burst<br />
of insulin that in turn helps to deliver<br />
blood glucose into the body’s cells,<br />
where it is used for energy.<br />
This insulin is released as a “squirt”<br />
or a “pulse” that is called a bolus. In<br />
someone without diabetes, a bolus of<br />
insulin keeps blood glucose levels in<br />
range after meals.<br />
Figure 1 shows normal insulin delivery<br />
in a person without diabetes. The top<br />
portion shows the blood glucose curves<br />
during a day in which someone eats<br />
three meals. The bottom portion shows<br />
the blood insulin levels for the same<br />
three meals. In basal-bolus therapy, the<br />
insulin doses and times are designed to<br />
match normal insulin delivery as closely<br />
as possible.<br />
Blood Glucose<br />
Blood <strong>Insulin</strong><br />
Midnight<br />
Figure 1<br />
Normal <strong>Insulin</strong> Delivery in People<br />
without Diabetes<br />
High<br />
Normal<br />
Low<br />
Basal<br />
3<br />
AM<br />
6<br />
AM<br />
Bolus<br />
9<br />
AM<br />
Noon 3<br />
PM<br />
6<br />
PM<br />
9<br />
PM<br />
Midnight<br />
If you have type 1 diabetes, your pancreas<br />
cannot make insulin. To use flexible<br />
therapy with basal-bolus insulin, you will<br />
decide how much insulin to take to keep<br />
blood glucose within your goal range.<br />
3
TERMS TO LEARN FIRST<br />
4
TERMS TO LEARN FIRST<br />
The goal of flexible therapy is to imitate<br />
the way a normal pancreas works. In<br />
someone who does not have diabetes,<br />
insulin automatically works at the right<br />
times, matching meals, activity or stress.<br />
When you have diabetes and use flexible<br />
therapy, you have to figure out and<br />
deliver the correct dose of bolus insulin<br />
yourself. Your Diabetes Team will guide<br />
you along the way. Your Diabetes Team<br />
may include your doctor, certified<br />
diabetes educators such as a diabetes<br />
nurse educator and a registered dietitian.<br />
Some teams also include an exercise<br />
physiologist, social worker and<br />
pharmacist. This section teaches<br />
you words you need to know before<br />
you begin.<br />
Blood Glucose Goals – The range<br />
your blood glucose should fall into most<br />
of the time. The American Diabetes<br />
Association (ADA) recommends the<br />
following blood glucose goals of<br />
90-130 mg/dl before meals and less<br />
than 180 about 2 hours after a meal.<br />
Your Diabetes Team will help you set<br />
your goals, for your blood glucose.<br />
Target Glucose – A single number<br />
that falls within your blood glucose<br />
goals. The target glucose is used to<br />
adjust your insulin dose.<br />
Algorithm – A formula that helps<br />
you determine the amount of insulin<br />
that you take before eating based on<br />
your current blood glucose level. Some<br />
people may have a different algorithm<br />
for each meal. Think of it as following<br />
a recipe. A sample algorithm looks like<br />
the chart below. This is only a sample.<br />
You should not use this table for<br />
treatment.<br />
SAMPLE ALGORITHM<br />
Pre-Breakfast Algorithm For Rapid Or Short<br />
Acting <strong>Insulin</strong><br />
If your Blood Your Rapid-Acting<br />
Glucose is: <strong>Insulin</strong> Dose should be:<br />
0-100: 2 units<br />
101-150 3 units<br />
151-200 4 units<br />
201-250 6 units<br />
251-300 8 units<br />
Over 300 12 units<br />
STEPS FOR USING A ALGORITHM<br />
1. Test your blood glucose.<br />
2. Find your reading in the blood glucose<br />
column.<br />
3. Check the rapid-acting insulin dose<br />
column to see how many units to take.<br />
For example, according to the algorithm if<br />
your blood glucose level were 184 mg/dl,<br />
you would need to take 4 units of rapid or<br />
short acting insulin before breakfast.<br />
5
NOTE: For an algorithm to work you<br />
need to eat the same amount of food<br />
and carbohydrate every day. (If you<br />
always have a sandwich with 2 slices of<br />
bread, a piece of fruit, a glass of milk<br />
and a small bag of chips for lunch, this<br />
method will be fine.) If you eat a big<br />
salad one day and a plate of spaghetti<br />
the next, these foods have different<br />
effects on your blood glucose and you<br />
would need different doses of insulin, so<br />
this is not the best way for you to decide<br />
how much insulin to take before meals.<br />
Basal <strong>Insulin</strong> – Works steadily day<br />
and night to keep your blood glucose<br />
within your goal levels. Taken as an<br />
injection, basal insulin is long acting and<br />
works around the clock. Taken via insulin<br />
pump, a very small amount of basal<br />
insulin is released constantly at fractions<br />
of a unit per minute. The goal is to<br />
match the amount of insulin with the<br />
low level of glucose produced by your<br />
liver. This helps your blood glucose levels<br />
remain stable day and night - even if you<br />
don’t eat anything. Types of basal insulin<br />
include:<br />
• Long-acting insulin such as insulin<br />
glargine (Lantus ®) is often used for<br />
basal insulin because they last a long<br />
time and have no peak action.<br />
• Ultralente - occasionally used as<br />
basal insulin, does have some peak<br />
action. (See Peak Action.)<br />
• Short or rapid-acting insulin (see<br />
below) given by an insulin pump –<br />
tiny amounts of rapid acting insulin<br />
are delivered throughout the day<br />
and night. This is the best example<br />
of basal insulin and may be closest<br />
to imitating the way the pancreas<br />
normally works. Another advantage<br />
is that basal rates on a pump can<br />
be changed to meet your needs at<br />
different time periods of the day<br />
and night.<br />
Bolus <strong>Insulin</strong> – Taken before you<br />
eat and to correct for a high blood<br />
glucose, it is released in a squirt or pulse.<br />
This allows the insulin to provide a rapid<br />
burst of action. Bolus insulin acts as the<br />
“extra” insulin that is released by a<br />
normal pancreas to help your body use<br />
the glucose from a meal or snack. The<br />
extra insulin will bring your blood glucose<br />
levels down before they climb too high.<br />
Types of Rapid-acting insulin used for<br />
bolus insulin are:<br />
• <strong>Insulin</strong> Lispro (Humalog ®), <strong>Insulin</strong><br />
Aspart (Novolog ®), <strong>Insulin</strong> glulisine<br />
(Apidra) or<br />
• Regular insulin, which is referred to<br />
as a short-acting insulin.<br />
6
<strong>Insulin</strong> <strong>Adjust</strong>ment and<br />
Pattern Management –<br />
<strong>Adjust</strong>ing insulin doses based on a<br />
pattern of blood glucose readings over<br />
three days or more is called “Pattern<br />
Management,” or “Pattern Control.”<br />
If your blood glucose is too high or too<br />
low at certain times of the day or night,<br />
an adjustment to your insulin dose may<br />
be needed. In this case it is helpful to<br />
look for patterns in your blood glucose<br />
readings over three days or more. For<br />
example, take a look at Jean’s blood<br />
glucose readings before dinner for the<br />
past three days:<br />
JEAN’S THREE-DAY BLOOD GLUCOSE RECORD<br />
(Goal 90 mg/dl-130 mg/dl)<br />
Breakfast Lunch Dinner Bedtime<br />
98 mg/dl 129 mg/dl 250 mg/dl 150 mg/dl<br />
89 mg/dl 105 mg/dl 225 mg/dl 111 mg/dl<br />
102 mg/dl 88 mg/dl 240 mg/dl 138 mg/dl<br />
You can see that her dinner numbers are all<br />
too high. The problem may be related to<br />
how much carbohydrate (carb) she ate at<br />
lunch, snacking, schedule or basal insulin.<br />
However, it is most likely that her food at<br />
lunch did not match her pre-lunch bolus.<br />
She ate too much carb for her insulin bolus<br />
dose. For more information on Pattern<br />
Control or Pattern Management, see the<br />
<strong>BD</strong> Publication: Pattern Control.<br />
<strong>Insulin</strong> Sensitivity Factor<br />
(ISF) and Correction –<br />
• ISF is the amount that one unit of<br />
rapid- or short-acting insulin will<br />
lower your blood glucose reading.<br />
It is used to calculate your correction<br />
or supplemental dose.<br />
• Correction dose is the amount of<br />
insulin you need to correct a high<br />
blood glucose level and bring it into<br />
the range your blood glucose should<br />
fall into most of the time.<br />
Once you know your ISF, you can give<br />
yourself the right dose of insulin to keep<br />
you within your blood glucose goals. The<br />
ISF is different for different people and<br />
your Diabetes Team will help determine<br />
it for you. For instance, if your blood<br />
glucose at lunch is 200 mg/dl and your<br />
goal is 90-130 mg/dl, you will learn to<br />
take a correction dose, an extra amount<br />
of rapid- or short-acting insulin to bring<br />
your high blood glucose down to the<br />
range your blood glucose should be in<br />
most of the time. Correction is usually<br />
required before a meal, so you will need<br />
to add or subtract this dose of insulin to<br />
the amount of insulin needed for your<br />
carbohydrate intake. The correction dose<br />
is extra insulin if your blood glucose is<br />
too high or a lower insulin dose if your<br />
blood glucose is to low.<br />
7
EXAMPLE:<br />
Calculating Laurie’s Correction Dose<br />
• Laurie’s ISF is 1 unit of rapid or short<br />
acting insulin for every 50 mg/dl of<br />
blood glucose.<br />
• Her target pre-meal blood glucose is<br />
100 mg/dl, but her pre-dinner blood<br />
glucose reading is 250 mg/dl.<br />
• She is 150 mg/dl over her target level.<br />
Current blood glucose – target blood<br />
glucose = amount of glucose over target<br />
[250 mg/dl – 100 mg/dl = 150 mg/dl]<br />
• Using Laurie’s ISF, she would divide<br />
150 mg/dl by 50 to find that she<br />
would need to add an extra 3 units<br />
of rapid or short acting insulin to her<br />
meal-time dose to correct the blood<br />
glucose to 100 mg/dl.<br />
Amount of glucose<br />
over target<br />
ISF<br />
[ 150 = 3<br />
50 ]<br />
= correction dose<br />
If Laurie’s pre-dinner blood glucose was<br />
75, she would reduce her insulin dose in<br />
the same manner as outlined above.<br />
• Her target pre-meal blood glucose is<br />
100 mg/dl, but her pre-dinner blood<br />
glucose reading is 75 mg/dl.<br />
• She is 25 mg/dl below her target level.<br />
Current blood glucose – target blood<br />
glucose = amount of glucose over target<br />
[75 mg/dl – 100 mg/dl = -25 mg/dl]<br />
• Using Laurie’s ISF, she would divide<br />
25 mg/dl by 50 to find that she would<br />
need to subtract 0.5 units of rapid or<br />
short acting insulin to her meal-time<br />
dose to correct the blood glucose to<br />
100 mg/dl.<br />
Amount of glucose<br />
= correction dose<br />
over target<br />
ISF<br />
[ -25 = -0.5 units<br />
50 ]<br />
Peak Action – The time when insulin<br />
is working the hardest to bring blood<br />
glucose down. It is essential to know<br />
when your insulin peaks so that you can<br />
prepare for possible low glucose levels at<br />
these peak times. Types of insulin with<br />
peak action times are:<br />
Name of Type of Peak Action<br />
<strong>Insulin</strong> <strong>Insulin</strong><br />
Humalog ® , Rapid 30 min. to<br />
Novolog ® , 1 1/2 hours<br />
Apidra ®<br />
Lantus ® Long No peak action<br />
*Regular Short 2 to 4 hours<br />
*UltraLente ® Long 8 to 30 hours<br />
*NPH Intermediate 4 to 12 hours<br />
*Lente ® Intermediate 7 to 15 hours<br />
*Not commonly used in Flexible <strong>Insulin</strong> Therapy<br />
8
MAKING BOLUS INSULIN CHANGES<br />
9
MAKING BOLUS INSULIN CHANGES<br />
Your first step in learning how to make<br />
these adjustments should be to consult<br />
with your Diabetes Team. This section<br />
will give you the tools you need to adjust<br />
your bolus insulin effectively using<br />
flexible insulin therapy.<br />
Understanding How<br />
<strong>Insulin</strong> Works<br />
Different types of insulin work at<br />
different speeds. Their action can be<br />
described as basal (steady and longacting),<br />
bolus (rapid burst of action) or<br />
somewhere in between. They also act<br />
differently in how fast they start working,<br />
INSULIN ACTION CURVES<br />
when they are at their peak and the<br />
length of time they last. It is important<br />
to understand these differences in order<br />
to make the best decisions possible when<br />
adjusting your insulin dose. By knowing<br />
which insulin peaks and is active you will<br />
know which insulin to change if you are<br />
having hypoglycemia (low blood sugar)<br />
or hyperglycemia (high blood sugar).<br />
View the chart(s) and graph(s) below to<br />
help you understand the actions of many<br />
different types of insulin including<br />
Humalog ®, Novolog ®, Regular, NPH,<br />
Ultralente, Lantus ®, etc.<br />
<strong>Insulin</strong> Action Type of <strong>Insulin</strong> Onset of Action Peak Action Duration<br />
RAPID ACTING <strong>Insulin</strong> lispro<br />
(Used for bolus (Humalog<br />
insulin – taken<br />
before eating<br />
and to correct<br />
for a high blood<br />
sugar)<br />
® ),<br />
<strong>Insulin</strong> aspart<br />
(Novolog ® ),<br />
<strong>Insulin</strong> glulisine<br />
(Apidra ® 15 minutes 1/2 to 1-1/2 3 to 5 hours<br />
hours<br />
)<br />
Blood <strong>Insulin</strong> Level<br />
SHORT ACTING Regular 1/2 hour 2 to 4 hours 6 to 8 hours<br />
6AM 9AM Noon 3PM 6PM 9PM MidN 3AM 6AM 9AM<br />
<strong>Insulin</strong> Commonly Used in Flexible<br />
<strong>Insulin</strong> Therapy for a bolus dose:<br />
Rapid-acting insulin is the most<br />
common insulin used, but shortacting<br />
insulin is also used for<br />
this purpose.<br />
10
<strong>Insulin</strong> Action Type of <strong>Insulin</strong> Onset of Action Peak Action Duration<br />
LONG ACTING Ultralente<br />
(Use for basal<br />
insulin – taken<br />
in injection or<br />
in a pump to act<br />
through day and<br />
night to keep<br />
blood glucose<br />
levels stable)<br />
Lantus ®<br />
Approx.<br />
12 to 18 hours Approx.<br />
4 to 8 hours<br />
24 to 28 hours<br />
2 to 4 hours No peak, stable 24 hours<br />
Blood <strong>Insulin</strong> Level Blood <strong>Insulin</strong> Level<br />
6AM 9AM Noon 3PM 6PM 9PM MidN 3AM 6AM 9AM<br />
The most common insulin used for<br />
basal doses is Lantus ®, although<br />
Ultralente can also be used.<br />
<strong>Insulin</strong> Action Type of <strong>Insulin</strong> Onset of Action Peak Action Duration<br />
INTERMEDIATE NPH, Lente 1 to 3 hours 6 to 12 hours 18 to 24 hours<br />
6AM 9AM Noon 3PM 6PM 9PM MidN 3AM 6AM 9AM<br />
NPH insulin may be used as a partial<br />
basal dose in the evening. This is<br />
most commonly used with shortacting<br />
(regular) insulin as a bolus dose.<br />
Fill in the chart/graph below to show the action of the types of insulin you are taking now:<br />
My Bolus __________________ insulin:<br />
My Basal__________________ insulin:<br />
Graph your insulin curves below:<br />
Starts to work at: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _<br />
Peaks (Works hardest from) _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _<br />
Lasts until: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _<br />
Starts to work at: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _<br />
Peaks (Works hardest from) _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _<br />
Lasts until: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _<br />
7AM Noon 6PM 12MN 7AM<br />
11
Blood Glucose Monitoring:<br />
When to Test<br />
Checking your blood glucose levels is<br />
important. You need the information<br />
to 1) Make insulin changes, and<br />
2) See if you made the correct<br />
adjustments.<br />
Many people using flexible insulin<br />
therapy check their blood glucose<br />
before each meal and at bedtime.<br />
Your Diabetes Team may also ask you<br />
to check your blood glucose two hours<br />
after a meal. (This reading will show<br />
how well the mealtime insulin dose is<br />
working.) In addition, to make sure<br />
that you are not having hypoglycemia<br />
at night, it is sometimes important<br />
to check blood glucose at 3AM.<br />
The 3 AM blood glucose, although<br />
inconvenient, is important because<br />
it can help guide the decision to<br />
change your nighttime basal insulin.<br />
It is common for blood glucose to<br />
drop before 3 AM and then to rise<br />
by morning. Figure 3 shows the<br />
effects of different types of insulin<br />
on your blood glucose at different<br />
times of day.<br />
Figure 3<br />
Effects of Previous <strong>Insulin</strong> Dose on<br />
Blood Glucose Readings Tested at<br />
Mealtimes and Bedtime<br />
<strong>Insulin</strong> Dose Blood Glucose<br />
Breakfast Lispro Breakfast BGM<br />
Lunch Lispro Lunch BGM<br />
Supper Lispro Supper BGM<br />
Bedtime Lantus Bedtime BGM<br />
HINT: If your blood glucose meter can<br />
do mealtime averaging, this can help you<br />
find the times of day that your blood<br />
glucose levels are usually too high or low.<br />
Along with your careful reflections about<br />
your carbohydrate intake, stress and<br />
activity levels, this may also guide<br />
your insulin adjustments.<br />
12
Making Changes Using<br />
Pattern Management<br />
You can learn to adjust your insulin<br />
dose by looking at your pre-meal blood<br />
glucose levels over three or more days to<br />
see if you notice any special pattern. In<br />
the following example and throughout<br />
the workbook, assume that the blood<br />
glucose goals recommended by the<br />
American Diabetes Association are in use<br />
(pre-meal plasma values of 90-130 mg/dl,<br />
blood glucose 2 hours after meals less<br />
than 180 mg/dl.) 2 and a target of<br />
100 mg/dl.<br />
How to Evaluate Your Blood<br />
Glucose Record:<br />
• Record your blood glucose levels in<br />
column format (as below) to more<br />
easily identify a pattern. Many of the<br />
data management software programs<br />
will do this for you automatically<br />
when you download the data.<br />
• Look at the readings by group<br />
according to the time of day.<br />
• Select the blood glucose readings<br />
by group that are out of your goal<br />
range.<br />
Day # Breakfast Lunch Dinner Bedtime 3 AM<br />
Day 1<br />
Day 2<br />
Day 3<br />
Three-day Blood Glucose Record:<br />
Pre-meal Goals 90-130 mg/dl Post-meal Goals < 180 mg/dl<br />
Pre Post Pre Post Pre Post<br />
Guidelines for Pattern Management<br />
Any time you see a consistent pattern of<br />
either high or low blood glucose levels<br />
over a period of three days, you could<br />
adjust your insulin by:<br />
• Increasing the appropriate insulin or<br />
decrease the food eaten if the blood<br />
glucose levels are too high.<br />
• Decreasing the appropriate insulin or<br />
increasing the food eaten if the blood<br />
glucose levels are too low.<br />
Most of the time the appropriate meal<br />
to change or insulin to adjust is the rapid<br />
or short-acting insulin taken the meal<br />
before the “out of goal values” appeared.<br />
2 American Diabetes Association, Standards of Medical Care for Patients With Diabetes Mellitus. American<br />
Diabetes Association: Clinical Practice Recommendations, Diabetes Care. 27:Supl:10, 2005.<br />
13
Q&A PRACTICE PROBLEMS<br />
Q – What is the Pattern in Jane’s Three-day Blood Glucose Record?<br />
Pre-meal goals 90-130 mg/dl Post-meal goals < 180 mg/dl<br />
Day # Breakfast Lunch Dinner Bedtime 3 AM<br />
Pre Post Pre Post Pre Post<br />
1 – Mon 90 125 110 189<br />
2 – Tues 75 134 116 210<br />
3 – Wed 100 141 131 196<br />
Average 88 133 119 198<br />
A – Jane’s pre-breakfast, pre-lunch and pre-supper readings are in goal blood glucose<br />
range, but her bedtime readings are all high and out of range.<br />
Q – Does Jane Need an <strong>Insulin</strong><br />
<strong>Adjust</strong>ment?<br />
A – Maybe! But first she should think<br />
about whether she had eaten too much<br />
carb at dinner. Over the next few days,<br />
she should decrease her portion sizes of<br />
food at dinner she is eating (which will<br />
decrease the amount of carb). If there<br />
is no improvement in her blood glucose<br />
readings, Jane should look for other<br />
possible causes and solutions.<br />
Q – Could Jane’s dinner insulin<br />
(Humalog ®) be the reason that her<br />
bedtime glucose is out of range?<br />
A – If Jane suspects her dinner insulin<br />
needs to be adjusted, she could try<br />
increasing it by 0.5-1 unit. Over the<br />
next three to five days she would need<br />
to observe whether her bedtime blood<br />
glucose readings are improved.<br />
NOTE: It is very important to consider<br />
all possible causes for an out-of-goal<br />
blood glucose reading before you adjust<br />
your insulin dose. The nice thing about<br />
pattern management is that you can<br />
make a small change every few days<br />
with great safety!<br />
14
Q – What is Different About Tom’s Three-day Blood Glucose Pattern?<br />
Pre-meal goals 90-130 mg/dl Post-meal goals < 180 mg/dl<br />
Day # Breakfast Lunch Dinner Bedtime 3 AM<br />
Pre Post Pre Post Pre Post<br />
1 – Mon 90 125 110 239<br />
2 – Tues 75 134 116 73<br />
3 – Wed 100 141 131 266<br />
Average 88 133 119 193<br />
A – In this record, the breakfast, lunch<br />
and dinner values are in the goal range.<br />
However, the bedtime values are not<br />
only too high on average, but also too<br />
variable. Tom needs to look for and<br />
understand what caused the low value<br />
of 73 at bedtime on Tuesday.<br />
Any time you see a consistent pattern of<br />
either high or low blood glucose levels<br />
over a period of three days, you could<br />
adjust your insulin as follows. Either<br />
increase the appropriate insulin if your<br />
blood glucose levels are too high, or<br />
decrease it if your blood glucose levels<br />
are too low.<br />
REMEMBER:<br />
Most of the time, the appropriate insulin<br />
to adjust is the rapid or short-acting<br />
insulin taken at the meal before the<br />
“out-of-goal” values.<br />
• The change should be only 1 or 2<br />
units or 10% of the usual dose at<br />
that time of day and can be as small<br />
as 1/2 unit.<br />
• You can make changes every three<br />
days.<br />
• Make a change, evaluate the effect<br />
for a few days and then make a<br />
change again. You do not need to<br />
make big changes. (When blood<br />
glucose values are quite variable,<br />
extra caution is needed because<br />
making even a small change in insulin<br />
under these conditions might be<br />
dangerous).<br />
HINT: Sometimes it is too early for you<br />
to see a real pattern. In this case you<br />
should probably not make any changes<br />
and wait a few more days to see if a<br />
pattern emerges. Or, by waiting a few<br />
days you might find that your blood<br />
glucose levels came back into the goal<br />
15
ange without any insulin changes.<br />
Always make insulin dose changes only<br />
after a full examination of the blood<br />
Based on your results, fill out the answers<br />
to the following questions:<br />
1. Do you see a consistent pattern?<br />
________________________________<br />
2. Which insulin is affecting the pattern<br />
of your glucose levels?_____________<br />
3. What kind of change might have<br />
helped bring your blood glucose<br />
levels into goal range?_____________<br />
4. Do you want to wait a few more days<br />
before you make any change to see if<br />
there really is a pattern?____________<br />
5. Have you experienced changes in<br />
your stress and/or activity levels over<br />
the past three days?_______________<br />
6. Have your food choices or amounts<br />
been different than usual for you?<br />
________________________________<br />
glucose levels and do it carefully!<br />
If you are unsure, consult with your<br />
Diabetes Team.<br />
Record Your Blood Glucose for the Past 3 Days and Pick Out the Patterns You See<br />
Pre-meal blood glucose goals:________ Post-meal blood glucose goals:________<br />
Day # Breakfast Lunch Dinner Bedtime 3 AM<br />
1 – Mon<br />
2 – Tues<br />
3 – Wed<br />
Average<br />
Pre Post Pre Post Pre Post<br />
7. Are you experiencing hormonal<br />
changes (such as those during<br />
menstruation or perhaps related to<br />
any medication you may be taking)?<br />
________________________________<br />
8. Is your pattern of values before<br />
breakfast out of the goal range?____<br />
(If YES, this indicates that you need<br />
to change your basal insulin. Please<br />
refer to p. 37 for a discussion of this<br />
topic.)<br />
HINT:<br />
Some people find it easier to use a<br />
computer program to identify blood<br />
glucose patterns. If you are interested<br />
in this type of a program, contact your<br />
meter manufacturer for information<br />
on how to obtain one.<br />
16
Correcting for Blood Glucose<br />
That is Out of Range<br />
Know Your Blood Glucose Goals<br />
In this workbook, the American Diabetes<br />
Association (ADA) recommended premeal<br />
blood glucose goals of 90 to 130<br />
mg/dl will be used. If you are above 130<br />
mg/dl, you will increase your insulin;<br />
if you are less than 90 mg/dl you will<br />
decrease the insulin. Many people use<br />
a target of 100 and make adjustments<br />
if they are above or below this target.<br />
‘Correcting’ – The term used for an<br />
immediate change in your insulin dose<br />
based on one event, such as a:<br />
• Single out-of-target blood glucose<br />
level.<br />
• Change in a single meal (you are<br />
invited out to a French restaurant<br />
for dinner).<br />
• Change in your exercise routine<br />
(you are going for a bike ride).<br />
Correcting means you make a minor<br />
change in your insulin dose based on the<br />
event now, but go back to your usual<br />
insulin dose tomorrow.<br />
EXAMPLE:<br />
If you wake up and your blood glucose<br />
reading is 200 mg/dl but you want it to<br />
be 100 mg/dl, you would make an<br />
immediate insulin “correction.” To do<br />
this you would take a certain dose of<br />
short or rapid-acting insulin to bring that<br />
blood glucose value down to 100 mg/dl.<br />
NOTE:<br />
Correction doses of insulin are calculated<br />
for each person and may change<br />
throughout the day. People usually<br />
need a bigger correction dose at<br />
breakfast than at lunch and dinner.<br />
Methods of Correction – There are<br />
many ways to correct for an abnormal<br />
blood glucose value. The three most<br />
common methods will be discussed here.<br />
Check with your health care professional<br />
to see which method is best for you.<br />
Correction Method I – Fixed <strong>Insulin</strong><br />
Dose Based on Blood Glucose Value.<br />
Uses an algorithm (formula) to tell you the<br />
amount of insulin to take based on your<br />
blood glucose levels before meals and at<br />
bedtime. The carb you eat at each meal<br />
should be the same from day to day.<br />
EXAMPLE:<br />
Ken’s Diabetes Team gives him an<br />
algorithm of blood glucose values and<br />
insulin doses. Ken will give the insulin<br />
dose that corresponds to his current<br />
blood glucose.<br />
17
Ken’s Algorithm for Correction Method 1<br />
Blood Glucose Values <strong>Insulin</strong> Dose (Rapid or Short -Acting)<br />
Breakfast Lunch Supper Bed<br />
Joe’s Algorithm for Correction Method II<br />
Blood Glucose Values Pre-meal rapid or<br />
short acting insulin<br />
Less than 60 Subtract 3 units<br />
60-90 Subtract 1 unit<br />
90-130 Take usual dose<br />
130-200 Add 1 unit<br />
200-250 Add 2 units<br />
250-300 Add 3 units<br />
300-350 Add 4 units<br />
350-400 Add 6 units<br />
Over 400 Add 8 units<br />
Correction Method III – Change in<br />
<strong>Insulin</strong> Dose Based on Your <strong>Insulin</strong><br />
Sensitivity Factor<br />
As you learned earlier, your “<strong>Insulin</strong><br />
Sensitivity Factor” (ISF) tells you how many<br />
points lower your blood glucose will go for<br />
every 1 unit of short or rapid acting insulin<br />
you take. Method III uses your ISF to figure<br />
out how much to raise or lower your<br />
insulin dose to bring your blood glucose<br />
back to goal range. If you use Correction<br />
Method III before a meal you will need to<br />
add the correction amount of insulin to the<br />
amount of units needed to “cover” the<br />
number of carbohydrates you will eat. (See<br />
p. 28 for a discussion of carbohydrates.)<br />
REMEMBER:<br />
The ADA recommended pre-meal values<br />
of 90-130 mg/dl as a goal range are used<br />
in this workbook. Your Diabetes Team<br />
may set a different pre-meal goal for you.<br />
Calculating Your <strong>Insulin</strong><br />
Sensitivity Factor (ISF) –<br />
Your Diabetes Team may use any of the<br />
following methods to help find your ISF:<br />
1. <strong>Insulin</strong>/Blood Glucose Formula<br />
(One unit of rapid or short-acting<br />
insulin for every 50 mg/dl increase or<br />
decrease in your blood glucose level).<br />
2. Rule of 1500 - if you are using shortacting<br />
insulin (Regular).<br />
3. Rule of 1700 - if you are using rapidacting<br />
insulin (Humalog ®, Novalog ®,<br />
Apidra ®).<br />
ISF Method I – <strong>Insulin</strong>/Blood<br />
Glucose Formula<br />
With ISF Method I, you take one unit<br />
of rapid or short-acting insulin for every<br />
50 mg/dl increase or decrease in your<br />
blood glucose level.<br />
EXAMPLE:<br />
Blood glucose target is 100 mg/dl.<br />
John’s pre-lunch blood glucose is 180<br />
mg/dl and his <strong>Insulin</strong> Sensitivity is 50.<br />
His reading shows that he is above<br />
his target by 80 mg/dl.<br />
[180 mg/dl – 100 mg/dl = 80 mg/dl]<br />
He should take 1 (1.5 if you measure<br />
1/2 units) extra units at lunch.<br />
If his usual dose of rapid or short-acting<br />
insulin at lunch were 12 units, he<br />
would increase it by one and take<br />
13 or 13.5 units.<br />
19
PRACTICE PROBLEMS:<br />
Blood glucose target: 100 mg/dl<br />
Susan’s pre-lunch blood glucose<br />
is 205 mg/dl.<br />
Her reading shows that she is above<br />
her target by 105 mg/dl<br />
[205 mg/dl – 100 mg/dl = 105 mg/dl]<br />
Q – How many extra units should<br />
Susan take?<br />
105 mg/dl<br />
= 2 units<br />
50<br />
A – She should take 2 extra units. In this<br />
case she should take a total of 14 units.<br />
Bob’s pre-lunch blood glucose<br />
is 60 mg/dl.<br />
His reading shows that he is below his<br />
lower target by 40 mg/dl<br />
[100 mg/dl – 60 mg/dl = 40 mg/dl]<br />
Using ISF Method I he would:<br />
40 mg/dl<br />
= .8 units<br />
50<br />
• Round .8 units to 1 unit<br />
• Decrease his insulin dose by 1 unit.<br />
• Take a total of 11 units.<br />
Find Your Correction Dose for the<br />
Highest Pre-Meal Blood Glucose you<br />
had yesterday:<br />
ISF = 50 mg/dl Target = _____ mg/dl<br />
Pre-Breakfast Pre-Lunch Pre-Dinner<br />
Record yesterday’s pre-meal blood<br />
glucose readings.<br />
Take your highest pre-meal blood<br />
glucose and subtract your target goal:<br />
[_______ – ________ mg/dl = _________.]<br />
Target Goal<br />
Divide your answer by 50 and add the<br />
number to your usual insulin dose:<br />
[__________ divided by 50 = _________.]<br />
Add to your usual pre-meal dose.<br />
If You Had a Low Blood Glucose<br />
Yesterday, Figure out the <strong>Insulin</strong><br />
Dose You Need:<br />
Record yesterday’s pre-meal blood<br />
glucose readings.<br />
Take your lowest pre-meal blood glucose<br />
reading and subtract your target goal:<br />
[_______ – ________ mg/dl = _________.]<br />
Target Goal<br />
This will be a negative number.<br />
Divide your answer by 50 and subtract<br />
the number from your usual insulin dose.<br />
[__________ divided by 50 = _________.]<br />
Subtract from your usual pre-meal dose.<br />
The corrections above using ISF Method I<br />
should bring your blood glucose back to<br />
normal at the next meal if you make no<br />
20
other changes. Although any single meal<br />
may not correct properly, if after a few<br />
days they do not, you may have the<br />
wrong ISF or the wrong carb-to-insulin<br />
ratio for you. Work with your Diabetes<br />
Team would have to adjust the ISF and<br />
carb-to-insulin ratio.<br />
ISF Method II – Using the ‘Rule of<br />
1500’ – To get a good first guess at your<br />
insulin sensitivity, divide the sum of all of<br />
your daily insulin doses into 1500. 3<br />
1) Add all insulin doses<br />
10 units <strong>Insulin</strong> Regular<br />
12 units <strong>Insulin</strong> Regular<br />
13 units <strong>Insulin</strong> Regular<br />
+ 15 units <strong>Insulin</strong> Lantus®<br />
50 units<br />
PRACTICE PROBLEMS:<br />
1. Calculate your ISF using the Rule<br />
of 1500.<br />
Fill in all the insulin doses you take in one<br />
day and add them up:<br />
# of units Type of insulin<br />
Total units/day<br />
Rule of 1500<br />
2) Divide sum of insulin<br />
doses into 1500<br />
1500 = 30 mg/dl<br />
50 units of insulin<br />
EXAMPLE:<br />
Calculate Rita’s ISF Using the Rule of<br />
1500.<br />
If Rita took 10 units of Regular insulin at<br />
breakfast, 12 at lunch, 13 at supper, and<br />
15 units of Lantus ® at bedtime, her total<br />
would = 50 units a day.<br />
Dividing 50 units into 1500 would = 30.<br />
So as a first guess, each unit of insulin<br />
would lower Rita’s blood glucose by<br />
30 mg/dl. (See Rule of 1500 box below)<br />
3) Answer = ISF<br />
<strong>Insulin</strong> Sensitivity Factor =<br />
1 unit of short or rapid -<br />
acting insulin will lower<br />
blood glucose 30 mg/dl<br />
Divide 1500 by your total units of<br />
insulin/day<br />
1500<br />
=<br />
(your total units of insulin/day)<br />
The answer is your ISF (the number of<br />
points one unit of insulin will lower your<br />
blood glucose).<br />
3 Klingensmith, GJ. American Diabetes Association, Intensive Diabetes Management, Third Edition, 2003.<br />
p. 107. 2003.<br />
21
Fill in your pre-meal blood glucose<br />
values from yesterday and calculate<br />
your adjusted insulin dose using the<br />
steps below:<br />
Pre-Breakfast Pre-Lunch Pre-Dinner<br />
Circle your high pre-meal blood glucose.<br />
Subtract your target goal from your high<br />
pre-meal blood glucose.<br />
[_______ – ________ mg/dl = _________.]<br />
Target Goal<br />
Divide this number by your insulin<br />
sensitivity factor (ISF)<br />
(ISF)<br />
= ________<br />
Add the answer to your usual insulin dose.<br />
If you had a low blood glucose<br />
yesterday find the insulin dose that<br />
should be given:<br />
Take your low pre-meal blood glucose –<br />
your target = ____________.<br />
This will be a negative number. You will<br />
need to subtract insulin for correction.<br />
[_______ – ________ mg/dl = _________.]<br />
Target Goal<br />
Divide the number by your ISF and subtract<br />
answer from your usual insulin dose.<br />
[__________ divided by _____ = ______.]<br />
Subtract from your usual pre-meal dose.<br />
[Usual dose – __________ = __________.]<br />
Fill in the table below with your<br />
calculations using your own<br />
information:<br />
Pre-Breakfast<br />
Pre-lunch<br />
Pre-dinner<br />
Usual <strong>Insulin</strong><br />
Dose<br />
<strong>Adjust</strong>ed<br />
<strong>Insulin</strong> Dose<br />
REMEMBER:<br />
Guidelines for Taking Correction<br />
Doses for Out-Of-Goal Blood Glucose:<br />
1. Check your blood glucose about 2<br />
hours later. Use your post-meal blood<br />
glucose goal. In this booklet, the<br />
ADA recommendation of less than<br />
180 mg/dl is used.<br />
2. If your blood glucose is still not within<br />
your range of blood glucose goals,<br />
lower your ISF number (try changing<br />
by 5).<br />
3. If you have hypoglycemia (low blood<br />
sugar), increase your insulin sensitivity<br />
number.<br />
ISF Method III – Using the Rule of<br />
1700 – Another way to get a good<br />
first guess at your insulin sensitivity is<br />
to divide the sum of all of your insulin<br />
doses into 1700. 4<br />
4 American Diabetes Association, Intensive Diabetes Management, third Edition, p. 107. 2003.<br />
22
EXAMPLE:<br />
If you take 10 units of Humalog ® at<br />
breakfast, 12 at lunch and 13 at dinner,<br />
and you take 15 units of Lantus ® at<br />
bedtime, your total would = 50 units a<br />
1) Add all insulin doses<br />
10 units <strong>Insulin</strong> Humalog®<br />
12 units <strong>Insulin</strong> Humalog®<br />
13 units <strong>Insulin</strong> Humalog®<br />
+ 15 units <strong>Insulin</strong> Lantus®<br />
50 units of insulin/day<br />
Now you try it using the 1700 rule.<br />
PRACTICE: Calculate Your ISF Using<br />
the Rule of 1700.<br />
Using the chart below, fill in all the<br />
insulin doses you take in one day and<br />
add them up:<br />
# of units Type of insulin<br />
Divide 1700 by your total units of insulin/day.<br />
1700 = ________<br />
(your total units/day)<br />
Total units<br />
per day =<br />
The answer is your ISF (the number of<br />
points one unit of insulin will lower your<br />
blood glucose).<br />
Rule of 1700<br />
2) Divide sum of all insulin<br />
doses into 1700<br />
1700 = 34 mg/dl<br />
50 units of insulin<br />
day. Dividing this into 1700 would give<br />
you 34 (this number can be rounded up<br />
to 35). So as a first guess, each unit of<br />
insulin would lower your blood glucose<br />
by 35 mg/dl.<br />
Figure out your adjusted insulin dose<br />
based on your pre-meal blood<br />
glucose readings:<br />
Target Goal = ______________<br />
Fill in your pre-meal blood glucose values<br />
from yesterday in the chart above.<br />
Circle your high pre-meal blood glucose.<br />
Subtract your target goal from your high<br />
blood glucose reading.<br />
_______ – ________ mg/dl = _________<br />
Target Goal<br />
Divide this number by your ISF.<br />
(ISF)<br />
3) Answer = ISF<br />
<strong>Insulin</strong> Sensitivity Factor =<br />
1 unit of short or acting<br />
insulin will lower blood<br />
glucose 34 mg/dl<br />
Pre-Breakfast Pre-Lunch Pre-Dinner<br />
= ________<br />
Add the answer to your usual pre-meal<br />
dose.<br />
23
If you had a “low blood glucose”<br />
yesterday, figure out your correction<br />
insulin dose.<br />
Subtract your target goal from your low<br />
pre-meal blood glucose.<br />
_______ – ________ mg/dl = _________<br />
Target Goal<br />
This will be a negative number. You will<br />
need to subtract insulin to make the<br />
correction.<br />
Divide your answer by your ISF and<br />
subtract answer from your usual insulin<br />
dose.<br />
(ISF)<br />
= ________<br />
Subtract the answer from your usual<br />
pre-meal dose.<br />
________ – _________ = _____________<br />
Fill in the table below with your<br />
calculations using your own<br />
information:<br />
Pre-Breakfast<br />
Pre-lunch<br />
Pre-dinner<br />
Usual <strong>Insulin</strong><br />
Dose<br />
<strong>Adjust</strong>ed<br />
<strong>Insulin</strong> Dose<br />
Every time you take a correction dose for<br />
an out of goal blood glucose you should<br />
note the effect on your blood glucose. If<br />
your glucose correction doses never bring<br />
you back to your goal range, you should<br />
lower your sensitivity number. If you<br />
are under-correcting you are not giving<br />
enough insulin. You will know this<br />
because your high blood glucose<br />
readings will remain high and the low<br />
blood glucose readings will stay low.<br />
This means you need a larger correction<br />
dose, so reduce your ISF by 5.<br />
If you are over-correcting you are taking<br />
to much insulin. You will know this<br />
because your high blood glucose values<br />
will become low and your lows may<br />
become high. This means you need<br />
to decrease your correction dose,<br />
raise the ISF by 5.<br />
24
Correcting for Known<br />
Changes in Meals or Exercise<br />
You have learned to adjust insulin to stay<br />
within your blood glucose goals. <strong>Insulin</strong><br />
doses are also commonly adjusted for<br />
changes in diet or exercise. Changing<br />
your insulin dose based on what you will<br />
eat and the activity you plan to do is<br />
often called “insulin dosing.”<br />
Correcting for a Change in Meals<br />
Since most people do NOT eat the same<br />
thing every day, you need to learn how<br />
to calculate your short or rapid acting<br />
(bolus) insulin for different meals and<br />
different amounts of carbohydrates.<br />
If you are not sure about which foods<br />
are carbohydrates, discuss this with<br />
your diabetes educator. As with insulin<br />
correction for out-of-goal blood glucose,<br />
different methods are available for insulin<br />
dosing for a change in the food that is<br />
usually eaten at meals. One method<br />
involves adding or subtracting insulin for<br />
more or less food. Another way is to<br />
take a certain amount of insulin for a<br />
specific amount of carbohydrate. Check<br />
with your Diabetes Team to see which<br />
method they recommend for you.<br />
Both methods require that you learn how<br />
to count carbohydrates. In addition, you<br />
also need to learn how sensitive your<br />
insulin dose is to the carb you eat. This<br />
is called your Carb:<strong>Insulin</strong> Ratio. For<br />
information about carb counting, see the<br />
<strong>BD</strong> Publication “Carbohydrate Counting:<br />
Eat to Win” and talk to your diabetes<br />
educator.<br />
Calculating Your Carb:<strong>Insulin</strong> Ratio –<br />
A carb:insulin ratio is the amount of<br />
rapid or short acting insulin you need<br />
to match or “cover” the amount of<br />
carbohydrate you eat. Your ratio<br />
depends on how sensitive your blood<br />
glucose is to insulin. The more you<br />
weigh, the less sensitive your body is<br />
to insulin. The more sensitive you are<br />
to insulin, the more carbohydrate that<br />
will be covered by one unit of insulin.<br />
Knowing your ratio and how to<br />
calculate your mealtime insulin to<br />
match the carbohydrate in your meal<br />
gives you the greatest flexibility with<br />
improved glucose control. You will<br />
be much freer to eat what you want,<br />
when you want, with fewer concerns<br />
about high or low blood glucose.<br />
25
Method I: A Quick and Easy Way<br />
to Start<br />
Before you begin, keep the following<br />
guidelines in mind. Use 1 unit of insulin<br />
for every 15 grams of carbohydrate<br />
(1:15). Some people will need more<br />
insulin (1 unit for every 10 grams of<br />
carbohydrate). Others will need less<br />
insulin and use 1 unit for every 20 grams<br />
of carbohydrate. Most people with type<br />
1 diabetes have ratios between 6 and<br />
10, but you may want to start with<br />
a very sensitive level of 15 grams of<br />
carbohydrate per unit of insulin and<br />
see if this works for you.<br />
Method II: The Rule of 500: 5<br />
Add up all the insulin given for 24 hours<br />
and divide it into 500. The answer is<br />
your carb:insulin ratio.<br />
EXAMPLE:<br />
Your total insulin dose is 50 units.<br />
500 divided by 50 = 10<br />
Your carb: insulin ratio is 10:1<br />
Again, this is a starting point, you<br />
need to start with this ratio and adjust<br />
it based on your blood glucose records.<br />
Your Diabetes Team can guide you in<br />
this process.<br />
Keep Detailed Records for About<br />
One Week<br />
The best way to find your carb:insulin<br />
ratio is to use the following Food and<br />
Carbohydrate Counting Record below<br />
and write down:<br />
1. Everything you eat and how much<br />
you eat - you will need to weigh and<br />
measure! (If you know how to count<br />
carbs, include them. Otherwise, use<br />
tables or a calculator to figure out the<br />
carbs in all of the food you eat and<br />
record each amount.)<br />
2. Your insulin dose for each meal.<br />
3. Your blood glucose levels before<br />
the meal.<br />
4. Your blood glucose records after<br />
the meal. (Your blood glucose level<br />
should increase about 50 mg/dl<br />
2 hours after you eat. If it is much<br />
higher or lower than that, your<br />
<strong>Insulin</strong>:Carb ratio will need to<br />
be adjusted.)<br />
NOTE:<br />
If you have never used a carb:insulin<br />
ratio, discuss this with your Diabetes<br />
Team and let them guide you through<br />
this process. Also, like the ISF, you may<br />
have a different carb: insulin for each<br />
meal. Typically, this ratio is lower at<br />
breakfast.<br />
5 Warshaw, H.S. and Kulkarni, K., Complete Guide to Carb Counting. P. 146. American Diabetes Association 2001.<br />
26
Food and Carbohydrate Counting Record<br />
Brkfst AM<br />
time: PM<br />
Food Eaten Amount Grams Carb<br />
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _<br />
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _<br />
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _<br />
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _<br />
Total: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _<br />
Snack Time: Food Eaten Amount Grams Carb<br />
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _<br />
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _<br />
Total: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _<br />
Lunch AM<br />
time: PM<br />
Food Eaten Amount Grams Carb<br />
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _<br />
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _<br />
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _<br />
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _<br />
Total: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _<br />
Snack Time: Food Eaten Amount Grams Carb<br />
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _<br />
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _<br />
Total: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _<br />
Supper AM<br />
time: PM<br />
Carb<br />
goal:<br />
gms<br />
Carb<br />
goal:<br />
gms<br />
Carb<br />
goal:<br />
gms<br />
BG before<br />
meal<br />
BG before<br />
meal<br />
BG before<br />
meal<br />
BG 2 hours<br />
after meal<br />
BG 90 min<br />
after meal<br />
BG 90 min<br />
after meal<br />
<strong>Insulin</strong> Comments:<br />
<strong>Insulin</strong> Comments:<br />
<strong>Insulin</strong> Comments:<br />
Food Eaten Amount Grams Carb<br />
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _<br />
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _<br />
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _<br />
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _<br />
Total: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _<br />
Snack BG before snack_________<br />
Time: Food Eaten Amount Grams Carb<br />
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _<br />
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _<br />
Total: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _<br />
27
Method I – <strong>Insulin</strong> Dosing Based on<br />
Carb Intake – A set dose of insulin is<br />
given for a meal and a specific amount<br />
of carbohydrate is eaten at the meal. If<br />
you eat the usual amount of carbs, you<br />
take the usual amount of insulin. Your<br />
health provider will prescribe a specific<br />
amount of carbohydrate for each meal.<br />
If you eat more carbs, you take more<br />
insulin, as determined by your prescribed<br />
carb:insulin ratio. If you eat less carbs,<br />
you reduce your insulin, again using<br />
the ratio.<br />
EXAMPLES:<br />
George’s Health Team prescribed<br />
carbohydrates for his meals as<br />
follows:<br />
• 60 grams of carbohydrate for<br />
breakfast and lunch.<br />
• 70 grams of carbohydrates for<br />
supper.<br />
If George expects to eat more carbs, he<br />
will take more insulin, as determined by<br />
his prescribed carb:insulin ratio. If he<br />
plans on eating less carbs, he will reduce<br />
his insulin, again using the ratio.<br />
What should George do if he is going<br />
to change the amount of food he is<br />
going to eat? (George usually eats<br />
70 grams of carb for dinner, and he<br />
takes 7 units.)<br />
• If George is very hungry today and<br />
plans to eat 90 grams of carb for<br />
dinner, he would eat an extra 20<br />
grams of carb.<br />
• If his carb:insulin ratio is 10:1, for<br />
every 10 extra grams of Carb, he<br />
needs 1 extra unit, so for an extra<br />
20 grams, he needs 2 extra units<br />
of insulin.<br />
• In this case, for a 90-gram dinner,<br />
he would take 9 units of insulin<br />
(see the chart below).<br />
Usual Grams of Usual Dose of<br />
Carbohydrate <strong>Insulin</strong><br />
Carb:<strong>Insulin</strong> Ratio: 10:1<br />
70 Grams Carb 7 Units Humalog ®<br />
90 Grams Carb 9 Units Humalog ®<br />
28
Method II – <strong>Insulin</strong> Dosing Based on<br />
Carb:<strong>Insulin</strong> Ratio<br />
Unlike Method I, you do not have a<br />
usual amount of food that you take or<br />
a usual insulin dose. You simply use<br />
the Carb:<strong>Insulin</strong> Ratio to determine<br />
your dose.<br />
EXAMPLE:<br />
Mary’s Carb:<strong>Insulin</strong> Ratio is 10:1<br />
Mary is meeting an old friend at a<br />
favorite restaurant and she is planning<br />
to eat a 90-gram lunch. To figure out<br />
her insulin dose, knowing that her ratio<br />
is 10:1, all she has to do is to divide<br />
the number of carb by her ratio as<br />
follows:<br />
90 grams of carbohydrate divided<br />
by 10 units of insulin = 9 units of<br />
Humalog ®<br />
[ 90 = 9 units of Humalog ® ]<br />
10<br />
Correcting for a Known Change<br />
in Exercise<br />
Exercise lowers your blood glucose levels.<br />
If you have started an exercise program<br />
and your blood glucose levels are too low<br />
and you are using an insulin pump, you<br />
will need to adjust your basal insulin.<br />
(See “<strong>Adjust</strong>ing the Basal Dose” p. 37).<br />
This is the hardest of the adjustments<br />
because everyone responds to exercise<br />
differently. If you are giving bolus<br />
injections of insulin, you should lower<br />
your bolus dose before exercise. An<br />
example of how to do this can be found<br />
on p. 37.<br />
Try to measure your exercise by intensity<br />
(how hard you work) and how much<br />
time it takes. Think of your exercise<br />
as mild, moderate or intense.<br />
• Mild exercise – you will not sweat at<br />
room temperature, no matter how<br />
long you do it.<br />
• Moderate exercise – you will sweat<br />
after 15-30 minutes.<br />
• Intense exercise – you will start to<br />
sweat almost right away.<br />
The more intense your exercise and the<br />
longer it lasts, the more you will need to<br />
decrease you insulin.<br />
29
PUTTING IT ALL TOGETHER<br />
30
PUTTING IT ALL TOGETHER<br />
You have learned a lot of information<br />
about making changes to your bolus<br />
insulin doses. Now it is time to put<br />
these facts to work for you. This<br />
section will help you practice using<br />
your new knowledge in your<br />
everyday routine.<br />
Getting Started:<br />
A Five-Step Plan<br />
1. Define your target blood glucose<br />
level.<br />
2. Calculate your insulin sensitivity<br />
factor (ISF).<br />
3. Try starting a carb:insulin ratio of 10<br />
or 15 grams of carb:1 unit of insulin.<br />
4. Count the number of carbohydrates<br />
you will be eating.<br />
5. Reduce, if necessary for exercise.<br />
Tom’s Calculations:<br />
PRACTICE PROBLEMS:<br />
Tom’s Night Out<br />
Let’s look at how Tom uses the 5-step plan<br />
above to calculate his insulin adjustment.<br />
Tom has a fun evening planned. He is<br />
going out to an Italian restaurant for dinner<br />
with some friends after a game of singles<br />
tennis. When he tests his blood glucose<br />
before dinner, he finds it is 190 mg/dl.<br />
Here is his information for the five steps.<br />
• Blood Glucose Goals: 90-130 mg/dl<br />
• Target blood glucose level is 100 mg/dl<br />
• The initial ISF is 1 unit for every<br />
30 mg/dl of blood glucose. Tom’s<br />
total insulin dose is 50 units/day.<br />
Using the rule of 1500, 1500/50 = 30<br />
• The initial carb:insulin ratio is 10:1,<br />
1 unit of Regular insulin for every<br />
10 grams of carb. Using the rule<br />
of 500, 500/50 = 10<br />
• Tom is planning on eating about<br />
90 grams of carbohydrates<br />
• See below for step 5<br />
<strong>Insulin</strong> needed for carbohydrates 9 units (90 divided by 10)<br />
<strong>Insulin</strong> needed to correct for high blood glucose (190-100=90) divided by 30 (ISF)=3<br />
Total insulin for food and carb 9 + 3 = 12 units<br />
Reduction for high intensity exercise (Step 5) 3 units<br />
TOTAL amount of pre-dinner insulin 9 units<br />
31
Your Night Out –<br />
Using the Five Steps, calculate the answers in the chart below:<br />
Planned Food (Carbs) ________ Carbs<br />
Divided by Carb/<strong>Insulin</strong> Ratio ________ Carbs/U of <strong>Insulin</strong> =<br />
________ Units of <strong>Insulin</strong><br />
Current Blood Glucose ________ mg/dl<br />
Your Target Blood Glucose ________ mg/dl<br />
Current Blood Glucose – Target Blood Glucose ________ mg/dl<br />
Your <strong>Insulin</strong> Sensitivity Factor? ________<br />
Divide your Blood Glucose Calculation by <strong>Insulin</strong> Sensitivity ________ U of insulin<br />
Subtract for Exercise if Necessary ________ U of insulin<br />
Your Morning Breakfast and Run<br />
Let’s say you are going to eat 2 slices<br />
of toast (30 grams), a fried egg, hash<br />
browns (15 grams) and a 1/2 glass of<br />
juice (15 grams). This is a total of (60<br />
grams of carb), but you are going to run<br />
Your Morning Breakfast and Run<br />
2 miles before lunch. Using the five<br />
steps, use the space below to figure out<br />
your insulin adjustment based on your<br />
plans for breakfast and exercise:<br />
Now check the following chart and<br />
see how well you did!<br />
Planned Food (Carbs) 60 Carbs<br />
Divided by Carb/<strong>Insulin</strong> Ratio 8 Carbs/U of <strong>Insulin</strong><br />
60/8 = 7.5 U of <strong>Insulin</strong><br />
Current Blood Glucose 180 mg/dl<br />
Current Blood Glucose – Target Blood Glucose 180 – 100 = 80<br />
<strong>Insulin</strong> Sensitivity 30<br />
________ Total Dose<br />
Current BG – Target BG 80<br />
_______________________ = __ = + 2.5 U of insulin<br />
<strong>Insulin</strong> Sensitivity 30<br />
Reduction for Exercise (Should be Negative) -3 U of <strong>Insulin</strong><br />
Add Units of <strong>Insulin</strong> (7.5 U + 2.5 U -3 U) = 7 U TOTAL DOSE<br />
32
After correcting for food, elevated blood<br />
glucose and expected exercise, you<br />
would take 7 units of short-acting<br />
insulin.<br />
IMPORTANT REMINDERS:<br />
• After adjusting your insulin dose for<br />
exercise you must check to see if the<br />
insulin given was too much or too<br />
little. (Checking your blood glucose<br />
level before, during and after exercise<br />
will provide the information you need<br />
to change future doses.)<br />
• Talk to your Diabetes Team about<br />
how your doses are working for you.<br />
• Be sure to test for urine ketones<br />
if blood glucose levels are over<br />
250 mg/dl. 6 Do not exercise when<br />
you have ketones in your urine.<br />
• Eat a carb food if blood glucose levels<br />
are
ADJUSTING THE BASAL INSULIN DOSE<br />
34
ADJUSTING THE BASAL INSULIN DOSE<br />
<strong>Adjust</strong>ing the basal dose is more<br />
challenging than changing the bolus<br />
dose. Basal insulin is designed to always<br />
be working in the background to keep<br />
your blood glucose steady when you are<br />
not eating. The basal insulin has the<br />
major job of keeping your blood glucose<br />
normal during the night, if you do not<br />
eat or if you delay a meal. <strong>Insulin</strong> used<br />
to provide a basal dose include Lantus ®<br />
and Ultralente insulin and the basal<br />
setting on an insulin pump. This section<br />
will help explain how to make changes<br />
to your basal insulin.<br />
Testing the Nighttime Basal<br />
<strong>Adjust</strong>ing the basal insulin is done<br />
much less often than the bolus insulin<br />
corrections. The best way to check your<br />
basal insulin is to look at your nighttime<br />
and morning glucose readings first. It<br />
is easier and more important to be sure<br />
that the basal is correct at night, since<br />
you may be hypoglycemic (have a low<br />
blood sugar) at night but not know it!<br />
Many people become less sensitive to<br />
insulin between 3 AM and 7 AM. As<br />
a result, you could have a high blood<br />
glucose value when you wake up in the<br />
morning or you could have a low blood<br />
glucose level in the middle of the night.<br />
How to Test and adjust The Basal<br />
<strong>Insulin</strong> To Normalize Your Morning<br />
Blood Glucose<br />
1. Check your blood glucose at bedtime,<br />
at 3 AM and in the morning before<br />
you eat.<br />
2. Pick a day when your bedtime<br />
glucose is close to your goal range.<br />
3. Set your alarm for 3 AM and write down<br />
your blood glucose value after you test<br />
(it is too easy to go back to sleep and<br />
forget the reading you got at 3 AM).<br />
4. In the morning check your prebreakfast<br />
reading.<br />
5. Using the graph below (Figure 4),<br />
put a dot that matches each of your<br />
blood glucose readings - at bedtime,<br />
3 AM and fasting (pre-breakfast).<br />
6. Connect the dots.<br />
Blood Glucose<br />
Bedtime 3:00 AM Pre-Breakfast<br />
Figure 4<br />
Graph for <strong>Adjust</strong>ing Basal <strong>Insulin</strong><br />
400<br />
300<br />
200<br />
100<br />
0 Bed 3 AM<br />
Time<br />
Fasting<br />
35
7. Your graph should look like one of the 6 patterns shown in the next graph<br />
(Figure 5) and labeled A-F.<br />
Blood Glucose<br />
400<br />
300<br />
200<br />
100<br />
0<br />
Bed 3 AM<br />
Time<br />
Fasting Bed 3 AM<br />
Time<br />
Figure 5<br />
Patterns of Overnight Blood Glucose Values<br />
A B C D E F<br />
Fasting Bed 3 AM<br />
Time<br />
Fasting Bed 3 AM<br />
Time<br />
8. Select the example that looks the closest to the pattern of your Basal <strong>Insulin</strong> in<br />
Figure 4.<br />
9. Look up the change in Table 1 below. The table below will indicate the change to<br />
your basal dose that is needed.<br />
Table 1: Changes to Basal <strong>Insulin</strong><br />
Changes to Basal for an <strong>Insulin</strong> Pump<br />
Pattern What to do... Expected Pattern<br />
A Normal – leave alone Pattern A<br />
B Increase 10 PM - 3 AM Pattern A<br />
C Increase 10 PM - 3 AM Pattern A<br />
D Decrease 10 PM - 3 AM Pattern A or E<br />
E Increase 3 AM - 7 AM Pattern A<br />
F Decrease 3 AM - 7 AM Pattern B or C<br />
Pattern<br />
Changes to Basal for Lantus® or Ultralente<br />
What to do... Expected Pattern<br />
A Normal – leave alone Pattern A<br />
B Increase Lantus ® or Ultralente Pattern A<br />
C Reduce bedtime snack, keep insulin dose the same Pattern A<br />
D Decrease Lantus ® or Ultralente Pattern A or E<br />
E Increase or add bedtime Lantus ® or Ultralente Pattern A<br />
F Decrease bedtime Lantus ® or Ultralente<br />
or reduce bedtime snack<br />
Fasting Bed 3 AM<br />
Time<br />
Fasting Bed 3 AM<br />
Time<br />
Pattern A<br />
Fasting<br />
36
For many people, the suggestion under<br />
the column, What to Do will correct the<br />
problem and give an expected normal<br />
pattern A. In some cases, the pattern<br />
may require more than one change.<br />
The result of the first, usually safer<br />
change is shown under the column,<br />
Expected Pattern. You may want to<br />
make a second change based upon the<br />
new problem. Talk to your Diabetes<br />
Team about how that change should be<br />
made. Changing more than one dose of<br />
insulin at a time can be complicated and<br />
should be left to your Diabetes Team.<br />
How much to change the insulin is<br />
very individual, please check with your<br />
Diabetes Team for advice. It is safest to<br />
make small changes often rather than<br />
big changes infrequently.<br />
Time of Day<br />
Meal<br />
Breakfast - Day 1<br />
Lunch - Day 2<br />
Lunch - Day 3<br />
Testing the Daytime Basal<br />
Your health care provider may ask you<br />
to check your daytime basal dose. Here<br />
are a few methods to use. Follow your<br />
provider’s best recommendation for your<br />
individual case.<br />
Option I: Skip a meal<br />
(the simplest method).<br />
• Day 1 - skip breakfast, then check<br />
your blood glucose every 2 hours,<br />
until lunch)<br />
• Day 2 – skip lunch and check your<br />
blood glucose every 2 hours, until<br />
dinner<br />
• Day 3 – skip dinner, again checking<br />
your blood glucose every 2 hours,<br />
until bedtime<br />
• In all cases, if your blood glucose<br />
is rising, your basal is too low; if<br />
it is falling, your basal is too high.<br />
Blood Glucose Results to Test Daytime Basal Rate<br />
37
Option II: See if your basal rises after<br />
your last bolus has finished working.<br />
(This only works with rapid or shortacting<br />
insulin.)<br />
Time of Day<br />
Meal<br />
Breakfast - Day 1<br />
Lunch - Day 2<br />
Lunch - Day 3<br />
Option III: Delay a meal and measure<br />
the effect on your blood glucose.<br />
Whichever method you choose, decide<br />
if you need a change in your basal dose<br />
and do it very carefully. Your Diabetes<br />
Team may recommend that you collect<br />
data over two time periods before<br />
making a change. It is also advised that<br />
this process be used on nights or days<br />
when your activity level is similar to your<br />
usual pattern. Small dose changes can<br />
• Measure your blood glucose four<br />
hours after you take your rapid or<br />
short-acting insulin.<br />
• Continue to measure your blood glucose<br />
every hour until you are sure that your<br />
blood glucose is not rising or falling.<br />
Blood Glucose Results to Test Daytime Basal Rate<br />
have a BIG effect on your blood glucose<br />
levels!<br />
After you make your adjustments, keep<br />
checking your blood glucose closely for<br />
the next few days. You need at least 4<br />
days to 1 week to see if your adjustment<br />
resulted in better blood glucose control.<br />
An adjustment on the basal rate for<br />
an insulin pump may take less time to<br />
evaluate. Use a chart like the following<br />
to write down your blood glucose results.<br />
Day Breakfast Lunch Bedtime 3 AM<br />
38
TROUBLESHOOTING<br />
39
TROUBLESHOOTING<br />
Sometimes you may find your blood<br />
glucose levels go up and down wildly,<br />
without any pattern that you can figure<br />
out. This might make you feel like giving<br />
up at times. Getting caught up in the<br />
frustration and anger just makes you feel<br />
more upset and hopeless. This section<br />
can help you cope with these feelings<br />
and put you on the right track to finding<br />
the answers you need.<br />
“I am doing everything right and my<br />
blood sugars still aren’t in my goal…<br />
I just don’t understand it anymore!”<br />
If this sounds like you it’s time to:<br />
• Take a deep breath.<br />
• Take a step back.<br />
• Put on your detective hat.<br />
• Figure out what is going on!<br />
Here are some guidelines to help you<br />
in your search for the answer. (There is<br />
an answer - really!) Although you may<br />
groan at the suggestion, the best way<br />
to figure out your problem is to keep<br />
written records.<br />
Go back to the drawing<br />
board with a record log that<br />
includes:<br />
• Pre-meal, 2 hours post-meal and<br />
bedtime blood glucose levels.<br />
• Time you eat.<br />
• Amount of carb you eat.<br />
• Amount and type of insulin you take.<br />
The Food and Carbohydrate Counting<br />
Record on p. 30 may be helpful.<br />
Now it is time to begin your<br />
detective work<br />
Round up the usual suspects and<br />
concentrate. Then ask yourself a few<br />
easy questions. Any time your answer<br />
is YES, place a checkmark in the<br />
appropriate box:<br />
1. <strong>Insulin</strong>:<br />
❑ Is there something wrong with<br />
your insulin? Was it allowed to<br />
get to warm or freeze?<br />
❑ Is it expired?<br />
❑ Are you giving it at the same time<br />
of day? Are you missing doses or<br />
giving it after a meal because you<br />
forgot to give it before?<br />
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2. Absorption of <strong>Insulin</strong><br />
❑ Are your injection sites lumpy<br />
or scarred?<br />
❑ Do you have any redness around<br />
your injection sites? Are you<br />
having trouble with your insulin<br />
pump infusion site or are you<br />
injecting in a scarred area? (This<br />
could affect how your body is<br />
absorbing the insulin and can<br />
lead to problems with control.)<br />
❑ Have you changed how you<br />
give insulin?<br />
❑ Have you changed the brand of<br />
syringe or size of insulin needle?<br />
❑ If you are using an insulin pump,<br />
is the tubing clogged?<br />
3. Stress<br />
❑ Are you experiencing unusual<br />
stress?<br />
❑ Did you know both physical and<br />
emotional stress could affect your<br />
blood glucose levels?<br />
4. Infection<br />
❑ Do you have an infection?<br />
❑ Did you know infections are<br />
a stress to the body and can<br />
increase blood glucose levels?<br />
5. Illness<br />
❑ Are you ill? Do you have a fever,<br />
a cold, or a virus?<br />
❑ Did you know illness could<br />
increase blood glucose levels?<br />
6. Physical Activity<br />
❑ Have you changed your physical<br />
activity a lot?<br />
❑ Are you more or less active than<br />
usual? (If so, this can increase or<br />
decrease your blood glucose levels)<br />
7. Food<br />
❑ Are you eating more carb and not<br />
taking enough insulin?<br />
❑ Is it possible you are not counting<br />
your carbohydrates accurately?<br />
❑ Are you eating at the same time<br />
of day or does it vary?<br />
❑ Are you eating less and taking too<br />
much insulin?<br />
8. Self-Monitoring of Blood Glucose<br />
and Test Strips<br />
❑ Are your test strips outdated or<br />
have the strips been outside the<br />
vial? (This will make your glucose<br />
readings inaccurate.)<br />
❑ Are you checking at the right<br />
time of day to understand the<br />
effect of your insulin, food and<br />
physical activity?<br />
❑ Did you clean your hands before<br />
checking your blood glucose?<br />
Even small amounts of food<br />
residue can affect results.<br />
If you answered YES to any of the above<br />
questions, correct the problem, give<br />
yourself a few days and see if your<br />
blood glucose levels out.<br />
If you answered NO to all of the above<br />
questions, your next step is to sort<br />
through your insulin doses.<br />
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Which <strong>Insulin</strong> is the<br />
Problem?<br />
1. Basal <strong>Insulin</strong><br />
❑ Am I taking enough or too much<br />
basal insulin?<br />
❑ Are my blood glucose levels<br />
always too high or too low?<br />
2. Bolus <strong>Insulin</strong><br />
❑ Is my bolus insulin dose correct?<br />
❑ Are my blood glucose levels<br />
too high or too low 2 hours<br />
after eating?<br />
8 AM 12 noon 6 PM 10 PM<br />
BG Ins BG Ins BG Ins BG Ins<br />
Day 1 94 10 L 104 8 L 205 13 L 150 1 LP<br />
19 G<br />
Day 2 108 10 L 103 8 L 197 13 L 155 1 LP<br />
19 G<br />
Day 3 97 10 L 112 8 L 215 14 L 125 19 G<br />
Now, read the questions below and circle<br />
the letter that you think is the correct<br />
answer to each question.<br />
1. What is the problem?<br />
A. Blood glucose too low at<br />
breakfast?<br />
B. Blood glucose too high at lunch?<br />
C. Blood glucose too high at supper?<br />
D. Blood glucose too low at<br />
bedtime?<br />
Read the following problem and see if<br />
it can help you figure out your basalbolus<br />
questions. Sam takes 19 units of<br />
insulin glargine (Lantus ®) at bedtime and<br />
insulin boluses of insulin lispro (Humalog)<br />
in the following amounts: 10 units for<br />
breakfast; 8 units for lunch, and 12 units for<br />
dinner. His mealtime carb amounts are 75<br />
at breakfast; 60 at lunch; and 100 grams<br />
at dinner. His insulin/carb ratio is 8:1 and<br />
his correction dose is 1 unit for every 50<br />
mg/dl and his target glucose is 100 mg/dl.<br />
On days 1-3 he always eats his normal<br />
amount of carb. He does not eat an<br />
afternoon snack. Look at his blood glucose<br />
values and insulin doses in the chart below.<br />
2. Which of the following types of<br />
problems does Sam have?<br />
A. A basal problem?<br />
B. A bolus problem?<br />
C. An eating problem?<br />
3. What should Sam do?<br />
A. Change the basal insulin glargine?<br />
B. Change the breakfast bolus?<br />
C. Change the lunch bolus?<br />
D. Change the supper bolus?<br />
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4. How much of an adjustment is<br />
needed?<br />
A. Decrease 1-2 Units<br />
B. Increase 1-2 Units<br />
C. Increase 3-4 Units<br />
D. Increase 5-6 Units<br />
ANSWERS:<br />
1. C – Sam has detected that he is<br />
always too high at supper.<br />
2. B – This is a bolus pattern that<br />
requires adjustment.<br />
3. B – He should change his lunch bolus<br />
4. B – He should increase his lunch bolus<br />
(insulin lispro Humalog ®) by 1 Unit.<br />
He should check back in 3 days to<br />
see if this was enough.<br />
Notice that while his dinner glucose<br />
values were too high, Sam was taking<br />
a correction dose of 1 unit of insulin<br />
for day 1 and 2. Since his blood glucose<br />
values were too high by about 75 mg/dl<br />
this was not enough and on day 3 he<br />
increased the correction to 2 units of<br />
insulin lispro (Humalog ®).<br />
If you have remaining basal-bolus<br />
questions, check back with your<br />
Diabetes Team.<br />
43
PROBLEM SOLVING AND EXERCISES<br />
44
PROBLEM SOLVING AND EXERCISES<br />
Use the problems and exercises in<br />
B. Increase the daytime basal rate<br />
this section to help you reinforce and<br />
by 0.2 units per hour?<br />
strengthen what you have learned<br />
C. Set her alarm and check her<br />
about insulin adjustment. The more<br />
blood glucose level at 3 AM?<br />
experienced you become at spotting<br />
D. Give a bolus at 10 PM?<br />
problems and figuring out the answers,<br />
the more rewards you will enjoy from<br />
practicing basal-bolus insulin therapy!<br />
A – Choice C is the correct answer - the<br />
only way to find out what is happening<br />
to Sally’s blood glucose level during the<br />
Sally’s on Goal at Bedtime but Gets night is to test it at 3 AM. Choice A -<br />
High Readings in the Morning<br />
Increasing the basal rate overnight might<br />
Sally has been using an insulin pump for cause hypoglycemia in the middle of the<br />
3 months. Her basal rate is set at 0.7 night. Choice B - Increasing her daytime<br />
units per hour from 10 PM to 3 AM and basal rate would do nothing to help the<br />
her daytime basal rate is 0.5 units per overnight blood glucose levels. Choice D -<br />
hour. She has been going to bed with Giving a bolus at 10 PM could cause a<br />
normal blood glucose values but always problem with hypoglycemia at midnight.<br />
wakes up with blood glucose levels over<br />
165 mg/dl. She increased her basal rate<br />
from 10 PM to 3 AM from 0.6 to the<br />
current rate of 0.7 units per hour but<br />
is still having a problem.<br />
Q – What should Sally do if she<br />
checks her blood glucose at 3 AM<br />
and discovers that it was 60 mg/dl?<br />
A. Lower the 10 PM to 3 AM basal rate?<br />
B. Eat a big snack at 10 PM?<br />
Q – What should Sally do to try to C. Decrease the snack bolus?<br />
bring her morning blood glucose level D. Increase the 10 PM to 3 AM basal rate?<br />
to her goal range of 90-130 mg/dl?<br />
A. Increase the basal rate from<br />
10 PM to 3 AM?<br />
A – Choice A is the correct answer.<br />
Sally has pattern D.<br />
Figure 5<br />
Patterns of Overnight Blood Glucose Values<br />
Blood Glucose<br />
400<br />
300<br />
200<br />
100<br />
0<br />
Bed 3 AM<br />
Time<br />
A B C D E F<br />
Fasting Bed 3 AM<br />
Time<br />
Fasting Bed 3 AM<br />
Time<br />
Fasting Bed 3 AM<br />
Time<br />
Fasting Bed 3 AM<br />
Time<br />
Fasting Bed 3 AM<br />
Time<br />
Fasting<br />
45
By lowering the 10 PM to 3 AM<br />
basal rate, Sally can avoid becoming<br />
hypoglycemic at 3 AM. By doing this,<br />
she may find that her fasting blood<br />
glucose level normalizes because she will<br />
not get a rebound high blood glucose in<br />
the morning. The other choices will not<br />
result in preventing hypoglycemia at 3<br />
AM. If her morning glucose rises higher,<br />
she can increase her 3 AM to 7 AM bolus<br />
dose.<br />
Jack Needs Help Figuring Out His<br />
Bolus Dose for Certain Meals<br />
Jack takes a bedtime basal dose of insulin<br />
glargine (Lantus ®) of 20 units and bolus<br />
meal doses based on a carb:insulin ratio<br />
of 12 grams of carbohydrate/unit and an<br />
insulin sensitivity factor (ISF) of 1 unit for<br />
every 40 mg/dl. His goal blood glucose<br />
range is 90-130 mg/dl, with a target of<br />
100. He exercises regularly and seems<br />
to do well on his current basal dose of<br />
insulin glargine.<br />
Q – What should Jack’s bolus dose be<br />
for the following breakfast meal?<br />
• His pre-meal blood glucose is 112<br />
mg/dl.<br />
• He will have 2 slices of toast,<br />
1 orange, 1 slice of cheese,<br />
1 cup of milk and coffee.<br />
A – Jack needs 5 units of rapid- or shortacting<br />
insulin for his meal of 60 grams<br />
of carb with a blood glucose within his<br />
blood glucose goals.<br />
Q – Can you find Jack’s bolus dose<br />
for the following dinner?<br />
• Jack’s pre-dinner meal blood glucose<br />
is 212 mg/dl.<br />
• He is planning to eat 2 pieces of<br />
bread, a salad with croutons and<br />
dressing, steak; large baked potato,<br />
side order of peas and broccoli. For<br />
dessert he will have 1/2 cup of vanilla<br />
ice cream with a small cookie.<br />
• Use this space to figure out Jack’s<br />
bolus dose before peeking at the<br />
following answer!<br />
Planned Food (Carbs) _____Carbs<br />
Divided by Carb/<strong>Insulin</strong> Ratio _____Carbs/U of<br />
<strong>Insulin</strong> = ___units of insulin<br />
Current blood glucose _____mg/dl<br />
What is Jack’s target blood glucose? _____<br />
mg/dl<br />
Current blood glucose - target blood glucose<br />
_____ mg/dl<br />
What is Jack's <strong>Insulin</strong> sensitivity factor? _____<br />
Divide Jack's blood glucose calculation by<br />
<strong>Insulin</strong> sensitivity<br />
_____ U of insulin<br />
_____ Total Dose<br />
46
A – Jack needs 13 units of insulin.<br />
Here’s why!<br />
• His carbs total 120 grams (bread =<br />
30 grams, croutons = 15 grams,<br />
large baked potato = 30 grams,<br />
peas = 15 grams, ice cream and<br />
cookie = 30 grams<br />
• His carb:insulin ratio is 12:1<br />
• 120 divided by 12 grams of carb per<br />
unit of insulin = 10 units.<br />
[ 120 grams of carb =10 units]<br />
12 grams of carb<br />
per unit of insulin<br />
• His blood glucose is 82 mg/dl over his<br />
target [212 – 100 = 112]<br />
• 112 divided by Jack’s ISF of 40 = 2.8<br />
units, round to 3 units.<br />
• 3 units + 10 = 13 units (Jack’s total<br />
bolus insulin dose for dinner)<br />
(correction dose + dose to cover meal<br />
based on carb:insulin ratio = total bolus)<br />
Jack Wants to Exercise More<br />
to Lose Weight – Should His<br />
<strong>Insulin</strong> Dosing Change?<br />
Jack thinks he could look better and<br />
decides to increase the intensity of his<br />
exercise program to lose weight. He has<br />
increased his walking from 20 minutes to<br />
45 minutes of brisk daily walks. Jack’s<br />
blood glucose levels for the past 5 days:<br />
Pre-breakfast Pre-lunch Pre-dinner Bedtime<br />
100 70 89 72<br />
85 100 88 65<br />
68 87 92 60<br />
90 68 66 80<br />
83 77 62 79<br />
Q – What should he do now?<br />
1. Change his insulin:carb ratio?<br />
2. Increase the amount of food he eats?<br />
3. Lower his basal insulin glargine?<br />
4. Change the insulin sensitivity factor<br />
to 1 unit for every 25 mg/dl?<br />
A – Looking at the pattern of blood<br />
glucose levels, it is clear that all the<br />
values are lower than the desired target<br />
of 100 mg/dl. The best response is<br />
Choice 3 – to lower the basal insulin<br />
glargine by 1-2 units, which will help<br />
bring the blood glucose levels higher<br />
overall. Choice 1 – any change to the<br />
bolus dose from changing his carb:insulin<br />
ratio will have little effect for the entire<br />
day. Choice 2 – increasing the amount<br />
of food, will only result in higher bolus<br />
doses and perhaps a weight gain, neither<br />
of which is desired. Choice 4 – changing<br />
the insulin sensitivity factor will result in<br />
higher doses of insulin and lower blood<br />
glucose values.<br />
47
Juan Has Had a Change in His<br />
Blood Glucose Levels<br />
Juan has had blood glucose levels within<br />
his goal range for the past several<br />
months on his basal/bolus insulin<br />
regimen of 10 units insulin glargine<br />
(Lantus ®) and pre-meal insulin doses<br />
of 6 units of insulin aspart (Novolog ®).<br />
He uses an ISF of 1 unit for every 50<br />
mg/dl and a target of 100 mg/dl.<br />
For the past 4 days his blood glucose<br />
values have increased to over 140 mg/dl<br />
consistently. He has not changed<br />
anything in his routine and is not sick.<br />
He always carries his insulin aspart with<br />
him in the car so it is available if he<br />
decides to stop and eat.<br />
Q – What Could Have Made Juan’s<br />
Blood Glucose Reading So High Over<br />
the Past Four Days?<br />
1. His car might have been too hot,<br />
causing his insulin not to work.<br />
2. Juan might have been under a great<br />
deal of stress.<br />
3. His blood glucose test strips might<br />
have expired.<br />
A – Any or all of the above choices could<br />
be correct. Choice 1 – <strong>Insulin</strong> must<br />
always be kept at least at room<br />
temperature. Juan would have to<br />
open a new bottle and watch his<br />
glucose levels closely. Choice 2 – If<br />
Juan is having unusual stress, he might<br />
need a small adjustment in his insulin<br />
while this is going on. Choice 3 –<br />
Expired blood glucose test strips could<br />
be giving him inaccurate readings.<br />
48
SEE – YOU REALLY CAN DO IT!<br />
49
SEE – YOU REALLY CAN DO IT!<br />
This workbook is only a starting point<br />
and guideline in your move to flexible<br />
therapy with basal-bolus insulin<br />
adjustment. The best approach is to<br />
consult your Diabetes Team and work<br />
on this together. If things go out of<br />
control, refer back to this “how-to”<br />
guide and do some of the exercises.<br />
Written by:<br />
Marjorie Cypress, RN, MSN, C-ANP, CDE<br />
Albuquerque, NM<br />
Like anything new, basal-bolus therapy<br />
is not easy at first and you will need help<br />
in learning how to adjust your insulin<br />
for food, activity, sleeping and waking.<br />
However, once you have learned these<br />
skills, you should be able to get your<br />
diabetes under excellent control and<br />
live a more flexible, healthy life.<br />
We wish to acknowledge the following health professionals for reviewing this publication and providing their valuable insights:<br />
Jean E. Betschart Roemer, CPNP, MSN, MN, CDE<br />
Pittsburgh, PA<br />
Linda Urso, APRN, BC-ADM<br />
Warren, MI<br />
Kathleen C. Arnold, CS-ANP, BC-ADM, CDE<br />
Gulfport, MS<br />
<strong>BD</strong> and <strong>BD</strong> Logo are trademarks of Becton, Dickinson and Company. ©2005 <strong>BD</strong>.<br />
All other brands are trademarks of their respective owners.<br />
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